| BackgroundThe importance of developing Community Healthcare Services (CHS) is to build a network stretching for public healthcare and medical service system. It is a basis for everyone to enjoy primary healthcare service, also an important part of the government’s social management and public service responsibility. It is of great significance to optimizing urban healthcare service structure, improving convenience for citizens enjoying medical service, reducing patients’medical cost burden and establishing a harmonious relationship between doctors and patients.Since1997when the Central Government called for an active development of CHS, primary urban CHS systems has been established in different regions. But, due to different social and economic development level in different regions, expenditures in local Community Healthcare Service Institutions (CHSI) are of big differences, social healthcare service development are unbalanced, some local CHSI are even in big difficulty in running in some regions.To ensure CHSI in normal running, policies to improve CHSI operation and management and related expenditure insurance mechanism have been making and improving. It is shown in the documents from the Central Government that all regions should actively explore reasonable and feasible social healthcare service revenue and expenditure operation management mechanism, can run trial sites by Separated Management of Revenue and Expenditure Budgets (SMREB) if conditions available; for government-run primary healthcare institutions, if the approved income is insufficient in covering all expenses, the gap should be fully made up by local government budget. At present, financial subsidies for most local government-run Community Healthcare Service Institutions are calculated by staff salaries and public healthcare service expenses. Since the second half of2005, SMREB has been explored in Shanghai, Hangzhou, Chengdu, Beijing and some other cities in CHSI management. However, as there is no official and practical SMREB definition, the policy is recognized and carried out in different ways from central to local governments.By whichever means of government subsidy, CHSI are facing some common problems in daily operations:for example, small investment proportion in community healthcare, lack of legislation guarantees and specific standards; financing capability from market becomes weaker after many tax-waiver policies are implemented; government financial burden and management costs are increased; in the long run, the sustainability of public finance investment also becomes a problem. Therefore, in order to effectively implement functions and realize significances of CHSI, a scientific and rational operation mechanism must be established to ensure the normal operation of CHSI.SMREB means that all income and expenditure of government-run CHSI should be included in budget management, all income should be paid to the government and all expenditures should be allocated from the government budget, it is a kind of management model that the government ensures the reasonability of expenditures, which concept is to emphasize the government’s responsibility, and the core goal is to cut off the chain of corruption interests, so that CHSI can return to public welfare. In May2009, the original Nanhui District and Pudong New Area were combined, and the new Pudong District was set up. Before combination, community healthcare service institutions in both districts had implemented SMREB reform since2007, but compensation mechanism and implementation effectiveness were different until2010when the compensation mechanism was unified. So, the research example of SMREB and compensation mechanism in the New Pudong area, Shanghai, can help us in studying and evaluating different compensation mechanisms comprehensively from the angle of specific cases, so as to further improve it. Moreover, this study on the form of SMREB and its concept and method, has theoretical significance for other regions in exploring comprehensive Development Index Method and enriching evaluation criteria on medical and healthcare institutions development, which therefore is of a certain academic value.ObjectivesSum up experiences and shortcomings, and analyze main problems and reasons by empirical study on SMREB and compensation mechanism of CHSI in New Pudong District. Put forward useful policy ideas, specific measures and necessary supporting conditions, based on domestic and abroad compensation experiences and relevant theories. The specific research objectives include following aspects:1. Studying the theoretical basis of the compensation for CHSI.2. Summarizing the compensation experience of CHSI domestic and abroad, policy changing and enlightenment.3. Empirical Study of SMREB and compensation mechanism for CHSI in New Pudong District before and after its foundation.4. Evaluating the influence on comprehensive development of CHSI from different compensation mechanisms.5. Analyzing problems and causes of the compensation mechanism of CHSI in the New Pudong area.6. Setting up appropriate methods about budgeting and expenditure in order to provide calculation basis for government investment amount.7. Putting forward suggestions and policy ideas on how to improve the compensation mechanisms in the new Pudong area.MethodsThis research used the methods of combining theory and practice, logical analysis and conclusion, quantitative study and qualitative analysis, through literature review, focus group interviews, site surveys, empirical researches, and other means of researches, by comprehensive healthcare statistical analysis, healthcare economic analysis and evaluations, as well as healthcare policy analysis and evaluation method tools, to give policy suggestions on how to improve the compensation mechanisms for CHSI.This study data comes from the database of China Academic Journal essays, professional books and papers of economics and healthcare policy management, central and local government policy documents, official statistical yearbooks, various types of financial statements, business reports and performances appraisal reports of CHSI.The qualitative data of this study was from focus group interviews of10experts from universities, government departments and CHSI leaders, questionnaires consulted about evaluation index system related to the Comprehensive Development Index (CDI) of CHSI. Evaluation index system of CDI were amended and finalized based on the comprehensive opinions of the experts, with site surveys questionnaires in14CHSI located in rural areas in the original Nanhui District and Pudong New District. Methods we used in specific data processing and analysis:1. Qualitative data analysis. Research applied inductive method of systematic review of relevant theory and classified analysis methods such as group interviews summarized.2. Descriptive statistical analysis. We made analysis on current and shifting trend of income and expenditure balance, resource development, healthcare service providing, medical cost control, operational efficiency and overall satisfaction of CHSI through descriptive statistical analysis.3. Comprehensive Development Index Method. Weighted calculation on index of CHSI system based on its own changes and development, to reflect the longitudinal trend and evaluate the comprehensive institution development.4. Health diagnostic tree method. From five aspects of financing, payment, organization, planning and behavior, the causes of the problems were analyzed in compensation mechanism in Pudong CHSI.5. The payment control model. For the healthcare material consumption for the community healthcare service, we take year as the repeated measuring factor, analyzing the influence from the medical income to material consumption through mixed model, to set up a healthcare material consumption control model. We also set up a public expenditure model based on amortization of service volume provided by CHSI, housing construction square, equipment value and staff numbers.Analysis tool were used mainly by Excel2010to establish a database and data collation, processing data descriptively. With Epidata3.1establishing analytical database, SAS9.1.3was used for statistical analysis, modeling, testing and parameter estimation.Conclusion1. Clarified the theory of public goods, institutional economics and welfare economics as the theoretical basis of this research. This study suggests that the current CHS is of dual properties as both public goods and quasi-public goods, the government must ensure the investment to improve the public accessibility to public goods. Equality and efficiency must be kept, urban and rural area gap must be narrowed in healthcare resources allocation, so that populations from cities and rural areas can enjoy the same level of basic healthcare services. But now, problems like institutional vacuum and system conflicts are still found in SMREB, which leads to system inefficiency. 2. Summarize experiences and enlightenments from domestic and abroad CHSI’s compensation methods and domestic compensation policy changes. Experience in developed countries included:utilizing market forces and private capitals to supplement the lack of government funds, paying attention to investment in demand-side, and actively playing the financing role of social healthcare insurance. The historical changes of the domestic compensation system showed that medical income and drug revenue are still in the dominant position of the institutional income. Although in2007all districts in Shanghai began to implement SMREB on CHSI, the concrete practice forms and compensation mechanisms were not the same. Certain results had been achieved in the increase of government investment and improvement of financial regulations. However, problems were also exposed in the lag of compensation and the difficulties in institution operations, further improvement is needed during the management of CHSI.3. Empirical Study of SMREB and compensation mechanism of CHSI in New Pudong District. The study showed that though both under SMREB, CHSI in the original Nanhui District took the compensation mechanism as "compensation gap", while CHSI in the former Pudong New District implemented "item grants" way, which have been still in use now. The same performance were turned out in increasing government funding year after year, rapid increase in total expenditure and in total amount of service provided, and slight increase in employee’s satisfaction. The different performances are in that since2007CHSI in northern area had been suffering years of losses, slow salary growth for employees and inefficiency control on medical costs, but the service efficiency per capita had improved significantly. However, CHSI in southern area, prior to the merger of the two districts, had balance of income and expenditure, increased employee salary and effective controls on healthcare costs, but the per capita efficiency was not high. After the merger, the institutions of the South are of the same performance as the North institutions.4. By comprehensive development index method, we evaluated the vertical development of CHSI from the points of view like total volume, efficiency, satisfaction, etc. We found that CHSI in south area before the merger were higher than CHSI in north, as well as than itself after the merger, in the development index of aggregate indicators and incentive indicators. But, the development index of satisfaction had little difference between south and north CHSI. Comprehensive analysis showed that prior to the merger of the two districts, south CHSI in the comprehensive development index were higher than northern institutions, as well as than its own2-year average after the merger. Therefore, in the compensation mechanism, the way of " compensation gap" adopted by the original Nanhui District were better than the way of "item grants" taken by the former Pudong New Area, in influencing the integrated development speed of CHSI.5. The main problems of compensation mechanism in New Pudong area were limited resources development, heavy losses, low operating efficiency and slight improvement in overall satisfaction. It was concluded that the integrated development speed of CHSI was cut down, primarily due to three reasons:the lack of total funding, the way of "item grants" and the lack of standards about budgeting and expenditure. Analysis showed that the way of "Compensation gap", determining the amount of government subsidies according to expenditure gap, was most in line with policy design of SMREB, made the budget of revenue and expenditures separated truly, and best embodied the ensuring responsibility of the government. So scientific and rational approving of budgeting and expenditure of CHSI was the basis and premise of SMREB.6. According to the specific content of revenue and expenditures of CHSI, the integrated use of three ways were taken to resolve the actual needs for budgeting work. First, revenue and expenditures were approved in accordance with the policy basis or mandatory, such as personnel expenses, union dues and welfare spending, capital expenditures, and public healthcare services funding. Second, revenue and expenditures were approved by the average growth rate method, which took the average growth rate of the past three to five years to estimate next year’s income or expenditure, such as medical income. Third, revenue and expenditures were approved by the payment control model, such as material consumption and operating expenses. After calculating, in2012the new Pudong District government needed to invest at least721million RMB to maintain the balance of payments of all CHSI.Suggestion1. For the means of compensation, learning from the practical experience of the original Nanhui District, the way of "compensation gap" should be taken by CHSI in the new Pudong area, in order to determine the amount of government subsidies according to expenditure gap, embody the budgeting authenticity and protect the normal operation of CHSI.2. Research suggested that revenue and expenditures were approved in accordance with the policy basis or mandatory, such as personnel expenses, union dues and welfare spending, capital expenditures, and public healthcare services funding. Medical income was approved by the average growth rate method. Material consumption and operating expenses were approved by the payment control model.3. Improving the incentive affect through revised performance appraisal. It could be taken that improving the performance appraisal index system, increasing the proportion of operating efficiency assessment, focusing on assessment involving indicators of service efficiency and cost control, such as volume of services, medical income, material consumption and operating expenses control, in order to promote services and operating efficiencies. Besides, the proportion and the way of the payment of wages could be changed by increasing the proportion of the performance appraisal in medical staff income.4. Clear division of responsibilities is necessary to solve the problem of excessive intervention from financial sector over the issue of economic operation of CHSI. The financial department is responsible for increasing funding, determining the total funding according to expenditure gap and supervision on budget execution. The healthcare sector should allocate the resources rationally, disburse funds flexibly under the annual budget flexibility and strengthen the supervision and assessment of institutional economic run. The CHSI has autonomy in day-to-day operation, management and development. Based on the government assigned tasks and self-development planning, CHSI has the responsibility of reasonable budgeting and requirements, strict implementation of the annual budget, the timely completion of the annual business revenue targets and active control costs.5. In order to give full play to the role of the compensation mechanism under SMREB in the new Pudong area, the support of the external policy environment are essential, besides the system itself should be reasonably configured and the understanding of the related parties should be unified. For example, SMREB approach should be revised and introduced to clear the government’s main responsibility; setting up year-on-year growth mechanism of medical staffs’ income could improve their enthusiasms and satisfactions; community healthcare service prices should be charged reasonably to enhance market-based financing ability; management on prepaid amount of total community healthcare insurance fees must be improved so that the remaining funds could be really translated into the disposable income of CHSI.; diversified financing channels should be set up to alleviate the financial burden. |
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